AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (32)

•Diagnostic Errors (22)

•Identification Errors (19)

•Discontinuities, Gaps, and Hand-Off Problems (67)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (138)

•Medical Complications (35)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (63)

•Transfusion Complications (1)

•Psychological and Social Complications (18)

Origin/Sponsor

•Australia and New Zealand (6)

•Europe (13)

•North America (537)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (20)

•Active Errors (98)

•Latent Errors (42)

•Near Miss (10)

Approach to Improving Safety

•Quality Improvement Strategies (149)

•Legal and Policy Approaches (34)

•Error Reporting and Analysis (123)

•Communication Improvement (142)

•Human Factors Engineering (101)

•Teamwork (60)

•Specialization of Care (45)

•Logistical Approaches (43)

•Culture of Safety (86)

•Technologic Approaches (76)

•Education and Training (134)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (464)

•Health Care Executives and Administrators (544)

•Non-Health Care Professionals (166)

•Patients (6)

Setting of Care

•Hospitals (331)

•Residential Facilities (2)

•Ambulatory Care (31)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 573

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COMMENTARY

Perinatal patient safety and quality.

Simpson KR. J Perinat Neonatal Nurs. 2011;25:103-107.

COMMENTARY

Improving patient safety with team coordination: challenges and strategies of implementation.

Harris KT, Treanor CM, Salisbury ML. J Obset Gynol Neonatal Nurs. 2006;35:557-566.

COMMENTARY

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.

COMMENTARY

Using technology to promote perinatal patient safety.

McCartney PR. J Obstet Gynecol Neonatal Nurs. 2006;35:424-431.

COMMENTARY

A system-wide initiative to prevent retained vaginal sponges.

Chagolla BA, Gibbs VC, Keats JP, Pelletreau B. MCN Am J Matern Child Nurs. 2011;36:312-317.

COMMENTARY

Perinatal patient safety from the perspective of nurse executives: a round table discussion.

Thorman KE, Capitulo KL, Dubow J, Hanold K, Noonan M, Wehmeyer J. J Obstet Gynecol Neonatal Nurs. 2006;35:409-416.

COMMENTARY

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.

COMMENTARY

Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system.

Deering S, Rosen MA, Salas E, King HB. Simul Healthc. 2009;4:166-173.

COMMENTARY classic

A 38-year-old woman with fetal loss and hysterectomy.

Sachs BP. JAMA. 2005;294:833-840.

COMMENTARY

In situ simulation: a method of experiential learning to promote safety and team behavior.

Miller KK, Riley W, Davis S, Hansen HE. J Perinat Neonatal Nurs. 2008;22:105-113.

COMMENTARY

A simple checklist for preventing major complications associated with cesarean delivery.

Duff P. Obstet Gynecol. 2010;116:1393-1396.

COMMENTARY

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

Tessier EG, Henneman EA, Nathanson B, Plotkin K, Heelon M. Am J Health Syst Pharm. 2010;67:607-611.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

COMMENTARY

Failure to rescue in neonatal care.

Gephart SM, McGrath JM, Effken JA. J Perinat Neonatal Nurs. 2011;25:275-282.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

COMMENTARY

Validating patient safety in the endoscopy unit using The Joint Commission standards.

Ragsdale JA. Gastroenterol Nurs. 2011;34:218-223.

COMMENTARY

Condition concern: an innovative response system for enhancing hospitalized patient care and safety.

Baird SK, Turbin LB. J Nurs Care Qual. 2011;26:199-207.

COMMENTARY

Battling the obstetric malpractice crisis: improving patient safety, part 1.

Bernstein PS. Medscape Ob/Gyn & Women's Health [serial online]. October 31, 2005;10(2).

COMMENTARY

Interruptions and medication errors: part I.

Flanders S, Clark AP. Clin Nurse Spec. 2010;24:281-285.

COMMENTARY

Building a safety culture.

Milligan F, Dennis S. Nurs Stand. November 2005;20:48-52.

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